Patient Name: Janina Priscilla Dayday

Date: April 8, 2024

Referral Source: Clinical Department
Data Source: Patient
Chief Complaint: Ms. J.D is a 9 y/old having an annual physical exam
History of Present Illness:
This is the first annual physical exam of a 9-year-old woman who claims that he has been experiencing a
strong headache for the last two to three hours and has not been feeling well. The right temporal side was
where the pain started. He had his first pain episode two to three days ago while studying. He claims that
after studying for about an hour or two, he started to feel the ache, but he did not have any nausea,
vomiting, or sweating. After around thirty minutes, the discomfort went away on its own when he did
nothing.

In general, He said that he has 2kg weight loss in the last 6 months.

Past Medical History:

The patient declined that he has any previous illness

Immunization History:

He takes immunization for Hepatitis B.

Allergies:

He said that he has an allergy to shrimp paste but he doesn’t have any action to it.

History of Family Illness:

The patient declined that their family has any health history problems

Review of Systems

HEENTS:

No complaints of headache change in vision, nose or problems, or sore throat.

Cardiovascular:

See HPI

Gastrointestinal:

No complaints in the epigastric part

Genitourinary:

No complaints of his genitalia area

Musculoskeletal:

He declines any muscle pain

Neurological:

He complained of no weakness or numbness.